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The safest place to have a baby in Canberra.

Canberra obstetrician Dr Andrew Foote is in today’s Canberra Times saying that “public hospital is safe, but private hospital is safer”. He is concerned that since government capped the Medicare Safety Net payments for obstetric services, women with private health insurance are choosing to have their babies in public hospitals because of the gap fees. He wants Medicare rebates lifted to cover the $2,000 average out of pocket costs.

For anyone wanting to know where is the safest place to give birth, it is worth having a look at ACT Health’s maternal and perinatal health statistics. For example, in 2008 the caesarean rate in Calvary Private was 32.6% and 43.6% at John James. In Canberra Hodpital public it was 23.9% (this includes the Birth Centre and high-risk Fetal Medicine Unit) and 26% at Calvary Public. Induction rates and caesareans with no prior onset of labour were highest in 2008 at Calvary and John James.

The rate of serious tearing (3rd or 4th degree) is higher in public hospitals – 3% at TCH compared to 1.2% at Calvary Private and 0.9% at John James. But the rate of intact perineums – no stitches at all – is 38% at TCH compared to 23% at Calvary and 23.7% at John James. There’s no breakdown of babies stay in special care by hospital, but TCH having the only NICU means they will have the babies who need the most acute care.

What Dr Foote hasn’t talked about in the Canberra Times article are the other factors that affect decisions about where to have babies. Both Calvary and John James hospitals are now run by Little Company of Mary. For women who prefer not to be in a Catholic hospital, which does affect the range of procedures and the information care providers are able to give women, TCH is the only alternative. Some women might prefer the model of care offered at the Birth Centre within TCH, which is quite different to the hospital maternity units. Equally, some women may be choosing Calvary Private or John James for the private rooms in recovery, which can only be accessed if you have a private doctor. Or they may prefer to see a doctor who works primarily at one particular hospital. Choosing a maternity hospital is far more complex than just the cost.

There are some statistics that are not available in the ACT Health publications, and the most recent data is from 2008. And of course, personal health history and philosophy (eg what risks and outcomes you can best cope with) are more important than stats in deciding what is best for an individual situation. No birth is risk-free, and it is good to be informed about how different outcomes can come about when choosing your model of care.

Women who medically require a surgeon are referred to a public obstetrician at TCH if they cannot afford private care. Increasing the Medicare Safety Net for obstetric services will almost certainly increase the costs to taxpayers for payments to private obstetricians. Around half of the total Medicare Safety Net budget was paid for obstetric services before the limitation was put in place. It will not necessarily improve the health of mothers and babies.

A better plan, in my opinion, would be to provide ACT healthcare consumers – women – with more detailed and up to date information about maternal and perinatal health outcomes, and all their options for maternity care. Perhaps as a booklet available from GPs and pharmacies, so women can get this information when they first find out they’re pregnant. The birth care that suits one woman might be unacceptable to another, so it is good to have multiple models of care offered in our community.

Dr Foote’s own research shows that women will choose what they believe is best for their baby and their own health, so why not just give the women the information and then respect their right to choose?

What’s Your opinion?

As for where to have a baby. The choice between a public shared crowded ward or a private room pretty much isn’t much of a choice. As for what the doctor offers to do, well that’s really more to do with the doctor you go to. I wouldn’t want to put my trust in some new registrar on duty at a public hospital.

As for the safest place to have a baby, I’m not sure any public or private hospital in Canberra is a safe place for any type of operation or health care…the risk of contracting MRSA (once called Golden Staph until it mutated into a potentially flesh-eating bacteria) or other serious bacterial infection is very high. They don’t tend to tell people that infection control is out the window, they don’t test for spread of these bacteria unless you have an obvious infection – and these bacteria can live on your skin for months or years before causing serious problems, during which time you would have infected your family and anyone else you’ve touched.

Hospitals know it’s out of control and have placed those hand sanitising pump bottles everywhere with some guff wording about how you should clean your hands to “protect patients”. Most people think these bottles are to stop the spread of flu only.

Worse still is that the main culprits for spreading bacteria are the staff – some nurses and a doctor in the infectious diseases ward told me that most health workers have MRSA on their skin and don’t worry about it as it is more serious for sick, immune compromised and elderly people. At the moment they isolate “known cases” at TCH but it’s known that certain wards are more ‘infectious’ than others at the hospital. Calvary Hospital doesn’t even isolate known cases but puts them into the general population even though it is extremely contagious through skin to surface contact.

Next time you are admitted to hospital make sure you ask this simple question before you let a nurse or doctor examine you – “Have you washed your hands?” and take along your own disinfectant to clean your shared toilet and shower if you are in a public hospital. It could save your life.

What’s wrong with having a baby in hospital the normal way? Don’t doctors know how to assist in pulling it out???

The training for obstetricians and midwives is quite different, as it should be. Obstetricians are experts in what to do when things are outside the bounds of normal and require life-saving intervention. Midwives are experts in what to when things are within the range of normal, and will refer the woman to an ob if it goes beyond that. So as an example, an obstetrician may have been trained to use an ultrasound to check baby’s position, or do a caesarean for breech birth, while a midwife may have been trained to feel for baby’s head with her hands and do vaginal breech deliveries. Obviously there is variation, some obs will do vaginal breech delivery if you’ve birthed vaginally previously. But my point is that they are different models of care and women need to consider their individual care provider’s philosophy as well as the comfortable room etc.

PigDog said :

Thanks, emd. But I meant does Dr Foote publish the results of his work as an Obstetrician? I.e. compared to his counterparts, what are the outcomes like for his patients. I assume he is safe, but is he the safest?

As far as I know, no obstetrician publishes stats on their own results, and the stats themselves could be misleading without context. For example, there are some obs in Canberra who specialise in high risk births, so their caesarean rates could be expected to be much higher than an ob who doesn’t have that specialisation. In the same way that John James’ higher caesarean rate could be in part attributed to their higher (than Calvary Private) rate of multiple births and older first time mum demographic. I do think it would be useful, though, for women who want a private doctor to easily find out what each private doctor’s specialisation or focus is, so you can choose the doctor that best suits their personal philosophy.

I also think we need more info in the ACT on how the new Medicare for midwives system and homebirth midwife registration works, who our private midwives are, and ensure they have visiting rights at the public hospitals in case of emergency transfer. Homebirth happens anyway, regardless of RANZCOG’s opinion, so we need to ensure that women have the protection of indemnity insurance, can claim back the same from Medicare as they would with any other care provider doing the job, and can transfer to hospital without worrying about whether they will be treated with respect.

When I saw this article in The Canberra Times the first thing I thought of was the high rate of caesarians in private compared to public. Also, how dare he use the term ‘safer’. This makes me angry and is a load of scaremongering in my opinion. The ob is rarely at the birth anyway. I had my babies at The Canberra Hospital and both times had my own room (you will always have your own room if they can) and found my level of care outstanding.

We didn’t have to pay for our parenting classes or breastfeeding classes or any others that we could have gone to where my friends going private had to pay. They also had to pay about $5000 upfront to see an Ob and then if they had to have a caesarian they had to pay for all kinds of costs associated with that too. I might have seen the same midwife a couple of times during my routine visits but all were very nice, friendly and caring. Indeed if there was an issue while I was pregnant then I would have hired an Ob but it’s up to the woman to make a choice of the type of care she wants.

I completely agree that women need to have all information at hand and make an informed choice.

The private hospitals are too under-staffed when having a baby. If you need care and are not concerned about having your own room then you are better off going Public. The out of pocket expenses are huge and you may not even see the OB you have paid a fortune for.

Yes, his research has been published by ANU Medical School. It was about why women are having elective caesareans. ….

Thanks, emd. But I meant does Dr Foote publish the results of his work as an Obstetrician? I.e. compared to his counterparts, what are the outcomes like for his patients. I assume he is safe, but is he the safest?

Sorry in advance for the giant post…I agree that women need to be provided with current information so that they can make an informed decision about these things.

I also think that some statistics presented can be misleading. For example the elective caesarean rate presents as higher at the private hospitals. I think people can interpret this as meaning that if you go private you’ll definately have a higher chance of being bullied into a caesarean. The numbers are always going to be higher for elective caesareans at private hospitals because some women choose to go private specifically so they can have an elective caesarean, a decision that these women have made long before the baby is due.

And as far as I’m aware (from people I know who’ve been through the public system) that’s not usually an option available to them. So someone who really wants an elective caesarean with no real medical need has no choice but to go through private.

I went through John James, a decision that was based on friends and relatives experiences in the public and private hospitals in canberra, as well as any research I was able to find. I think the decision was affected by my sister and two friends having absolute nightmare deliveries in the public hospital.

Things that I liked about going private were seeing my same obstetrician through the entire pregnancy and then having him there at the delivery. It was extremely familar and comforting. I also liked being able to choose to have a private room which helped with the recovery. I found there was exceptional care and instruction for me after the birth which was invaluable, they had a lot of time for us. I also didn’t find one hint of religiousness coming from anyone at the hospital. They were a bit over-zealous with the breastfeeding, but I’ve heard thats standard across the board. I’m sure plenty of people have had great care in the public hospital too.

red_dog said “Now I’ve no objection to an obstetrician being on hand if complications arise but I believe the vast majority of births do not (or should not) require their presence.”

This is a decision that should be made by the woman. Some women, like myself, found the obstetrician a good choice, and in hindsight having him there ended up saving mine and my kids life when things did get complicated.

But say you wanted a really natural, water-birth, home-delivery-feel you might find it hard to get an ob. who is comfortable with this and start to look at the birth centre, etc. Women need all the information, the positives and negatives about all of their options.

Not all obstetricians are cynical butchers just waiting to cut you open. A lot of them just support a womans right to choose to deliver however she feels like it. They’re going to have their own opinions on what is the best way too. They are human after all.

Of course they have to look after their own interests to an extent, their fees are high for a lot of reasons (insurance for the rest of their life being one of them) not just because they want to feather their own nests. If you do a good job you want to be paid for it, yes?

Good job to the OP and others on picking up Canberra Times lack of scrutiny on this more than slightly self interested Dr. In addition to the stats pointed out in the OP Dr Foote also doesn’t seem to take into account the different types of people using the different services. I imagine it is a very rare occasion that Calvary John James sees to the needs of junky mums in its private rooms. Surely the public sector, in taking the majority of people who are likely to have complications should be commended. I wonder if the statistics Dr Foote uses take into account this sort of discrepancy; and if they did would they in fact show that for a ‘run of the mill’ pregnancy you are actually safer in one of the public hospitals?

Yes, his research has been published by ANU Medical School. It was about why women are having elective caesareans. He found that the vast majority did so because they believed it was best for their baby or their own health, based on the advice their doctor had given them.

WHO recommends a safe caesarean rate of 15-20% – above that and there are probably women having major surgery and the accompanying risks who don’t medically need it. So when we read about rising caesarean rates – such as John James at 43% in 2008 – we should consider what advice doctors are giving and what training they’ve had, rather than putting all the pressure onto women (who in Canberra usually have only 1 or 2 babies in their lifetime) to research it.

So a private doctor is complaining because the government wont subsidise him for $2000 above what they subsidise a public doctor for? Maybe he should have studied economics and competition along with medicine.

Dr Foote delivered our first child at Calvary Private in January last year. Not having any expectations or prior experience we went through the whole process with an open mind. Inittialy our choice for private purely came down to a guarantee to our own private room for the duration of our stay and we are pleased we made the decission as the first week after your child is born is just a blur of sleep deprivation and a certain level of pain and incapacitation for my wife during her recovery. I was able to help with all this because I was allowed to stay with her in the room, I don’t believe this is possible in a shared public room.

As for a better delivery and care? I would like to think that money doesn’t buy this, I believe it should be the same for all women not those who can afford it. However after seeing some stats perhaps that is not the case?

For our next child, we will be going private again, our total out of pocket expensess after private health cover and the medicare sfateynet are worth it in my opinion. That being said perhaps all we are paying for is a guarantee to that privacy in the end because my sister had her first child through public at (the then new) QBN hospital and she had a private room the entire time, her second, prematurely at Canberra Hospital when she also had a private room.

As far as the “Catholic” side of things go, I am not a relgious person nor did I ever feel that at anypoint this was pushed upon us. There was no praying for a quick birth, a priest did not deliver our child and nuns don’t walk the corridor (from what I saw or remember… I might of been asleep though).

“so why not just give the women the information and then respect their right to choose?”

+1 Indeed … why not? Could it be that through education and informed choice women may choose alternatives to the fear and anxiety often peddled by Dr Foote and his bag of obstetric cronies. They are protecting their business interests after all. (And why do women insist on listening to men talking about how birth should be?)

Now I’ve no objection to an obstetrician being on hand if complications arise but I believe the vast majority of births do not (or should not) require their presence.